Musculoskeletal infections in intravenous drug addicts: report of 34 cases with analysis of microbiological aspects and pathogenic mechanisms.

OBJECTIVE: To analyse characteristics of musculoskeletal infections in Spanish intravenous (i.v.) drug addicts. METHODS: A retrospective analysis of 34 medical records was carried out and the aetiologic agent was confirmed in all cases. RESULTS: The mean age was 26 years and the sex ratio was 25M/9F. Twenty-four patients were HIV-positive and 10 HIV-negative. There were no differences between the 2 subgroups. Septic arthritis, seen in 27 cases (79%), was the most common type of infection. Axial involvement was present in 23 cases (67%). The organisms isolated included Staphylococcus aureus (25 cases), Candida albicans (3 cases), Mycobacterium tuberculosis (2 cases), and Neisseria gonorrhoeae, Salmonella typhi, Staphylococcus epidermidis and Streptococcus pyogenes in one case each. Candida albicans affected the sternocostal joints. Laboratory data showed non-specific findings. The outcome was mostly good and only one patient died. CONCLUSION: Human immunodeficiency virus does not affect characteristics of musculoskeletal infections in i.v. drug addicts. Staphylococcus aureus is the most frequently isolated pathogen in this population.

[Pulmonary Kaposi's sarcoma in a heterosexual parenteral drug addict patient with the acquired immunodeficiency syndrome]. / Sarcoma de Kaposi pulmonar en un paciente heterosexual adicto a drogas por vía parenteral con síndrome de inmunodeficiencia adquirida.

A case of Kaposi syndrome is described in a 28-year-old heterosexual male with acquired immunodeficiency syndrome. The disease began clinically with pulmonary disease, without mucocutaneous lesions. This form of presentation is extremely infrequent and has not been described in non-homosexual subjects. Clinical manifestations were fever, cough and dyspnea. Thoracic radiography observed a perihilar interstitial pattern which evolved to a bilateral nodular pattern with perihilar adenopathy. There was endobronchial disease, however pulmonary biopsy was required for diagnosis. Complete tumoral remission was achieved with adriamycin, bleomycin and vincristine.

[Good response to azidothymidine in 3 patients with vacuolar myelopathy]. / Buena respuesta a azidotimidina en tres pacientes con mielopatía vacuolar.

We report 3 drug abusers with human immunodeficiency virus (HIV) infection who had presented with myelopathic symptoms. A diagnosis of vacuolar myelopathy associated with HIV was made. The patients had a favorable response to azidothymidine. They were followed up as outpatients, and they showed a significant clinical improvement within 1-3 months of therapy. They remained stable 11 months afterwards. The patients with this type of disease may benefit from azidothymidine therapy.

[Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: an analysis of a series of 78 cases]. / Lesiones pulmonares cavitadas en los pacientes infectados por el virus de la inmunodeficiencia humana: análisis de una serie de 78 casos.

BACKGROUND: To assess the clinical, radiologic and microbiological features of lung cavitation and HIV infection. Evaluation of the differences related to this disease in the last years. PATIENTS AND METHODS: Retrospective review of all patients with lung cavitation and HIV infection admitted at our hospital from January 1989 until December 1994 and prospective study of all patients with the same characteristics during 1995 and 1996. Lung cavitation was defined as any parenchymal lesion, with air content, visible in a simple X-ray and greater than 1 cm of diameter. Criteria for confirmed, probable or possible diagnosis were defined. RESULTS: 78 cases of lung cavitation have been identified in 73 patients. The radiologic patterns included unilobar and multilobular involvement in 31 and 47 cases, respectively. Cavities were multiple and single in 40 and 38 cases respectively. Findings with fine needle aspiration biopsy (FNAB) were diagnostic in 11 out of 14 cases. A clinical diagnosis was performed in all 78 cases, with microbiological results in 69 cases (88.5%): Mycobacterium tuberculosis in 20, Pneumocystis carinii in nine, Pseudomonas aeruginosa in nine, Staphylococcus aureus in eight (5 endocarditis with cavitary septic emboli), Rhodococcus equi in six, P. aeruginosa and S. aureus in three, Salmonella enteritidis in three, Cryptococcus neoformans in two, Aspergillus fumigatus in two and others in 7 cases. Confirmed, probable and possible diagnosis was considered in 54, 15 and 9 cases, respectively. Thirteen episodes of spontaneous pneumothorax were found. CONCLUSIONS: The lung cavitation rate is low, compared with the number of admissions related to HIV infection; nevertheless, many of them are in close relationship with HIV infection, and most of them are caused by treatable infections. It is important to know the clinical and radiological characteristics, in order to establish an early diagnosis and an appropriate therapy. Pseudomonas aeruginosa is becoming an important cause of lung cavitation. In our series, spontaneous pneumo-thorax was not related to Pneumocystis carinii pneumonia in 61.5% of cases.

[The usefulness of the desensitization to rifampin in the treatment of mycobacterial disease in patients with AIDS]. / Utilidad de la desensibilización a rifampicina en el tratamiento de enfermedades producidas por micobacterias en pacientes con SIDA.

BACKGROUND: Hypersensitivity reactions to rifampin are relatively uncommon, but they may result in cessation of therapeutic medications. PATIENTS AND METHODS: We report our experience with oral desensitization protocol to rifampin in a group of 35 HIV-positive patients with mycobacterial disease who had some hypersensitivity reaction to this drug. RESULTS: Adverse reactions with this protocol were few and easily treated. CONCLUSIONS: Oral desensitization to rifampin is safe and effective, allowing some of these patients (60%) to reintroduce the drug and to reduce the time of treatment.

[Invasive aspergillosis in patients infected by the human immunodeficiency virus]. / Aspergilosis invasiva en pacientes infectados por el virus de la inmunodeficiencia humana.

Invasive aspergillosis is a disease that affects immunosuppressed patients, in close relationship with the presence and duration of neutropenia. Although formerly included among the AIDS definition criteria, it was thereafter dropped out because of its very low prevalence. We describe here four cases of invasive aspergillosis in HIV infected patients, diagnosed at our institution. Three patients presented with invasive pulmonary aspergillosis, including one patient with chronic ulcerative pulmonary aspergillosis. The fourth patient developed aspergillosis of the brain. Taking into account the difficulties in establishing a diagnosis of this infection before death (most of published cases were from autopsy reports) and because of the paramount importance of early diagnosis for improving survival, we support the use of invasive pulmonary aspergillosis diagnostic criteria in a similar way as used in patients suffering lymphoproliferative disorders. Although classic treatment of this infection is based on the use of amphotericin B (with or without 5 fluorocytosine), the potential usefulness of itraconazole (a new imidazole drug) has to be considered. In spite of the low number of published cases, we believe that invasive aspergillosis among HIV infected patients has to be included as a likely diagnosis, specially in view of the prolonged survival and widespread use of cancer chemotherapy in this population.

[Coinfection by mycobacteria in HIV-positive patients]. / Coinfección por micobacterias en pacientes HIV-positivos.

BACKGROUND: The aim of this study was to describe the clinical characteristics and therapeutic management of coinfection by mycobacteria in the authors hospital. METHODS: Two cases of coinfection detected in mixed cultures in agar 7H11 or simultaneous positive cultures in several evaluable clinical samples (blood cultures for MAI and M. kansasii and sputum or stools for M. tuberculosis). RESULTS: One coinfection by MAI and M. tuberculosis and another by MAI and M. kansasii in two severely immunosuppressed HIV positive patients with less than 0.010 CD4 lymphocytes/10(9)/l. The clinical manifestations were unspecific, with fever and deterioration of the general state predominating over the 30-45 days of evolution. One of the patients improved with treatment which, in both cases, included a macrolide. Survival was very short and death was by intercurrent causes. CONCLUSIONS: For the diagnostic of coinfection in severely immunosuppressed patients multiple organic samples should be taken and appropriately processed to detect the mixed cultures or the presence of different mycobacteria in different samples from the same patients. Although the diagnosis of the species is fundamental, the empiric treatment of a disease by mycobacteria in severely immunosuppressed patients should include at least: ethambutol and clarithromycin or azithromycin in addition to other first line tuberculostatic drugs until definitive identification.

[Administration of granulocyte colony-stimulating factor in patients infected with human immunodeficiency virus and prolonged neutropenia]. / Administración de factor estimulante de colonias de granulocitos en pacientes con infección por el virus de la inmunodeficiencia humana y neutropenia prolongada.

BACKGROUND: Persistent neutropenia is frequent in HIV infected patients with severe immunodeficiency. G-CSF induces proliferation and differentiation of granulocyte precursors. Our objective has been to assess the response to G-CSF therapy on patients with advanced HIV disease and prolonged neutropenia. METHODS: A retrospective analysis of databases containing demographic information, analytic controls and hospitalizations related to neutropenia for patients attending our Infectious Diseases Unit from December 1, 1992 to January 30, 98. The episodes with absolute neutrophil counts lower than 1,000 x 10(6)/l at least during 7 days which descend below 500 x 10(6)/l at any moment were included. RESULTS: 36 episodes were included. 9 episodes started on treatment with G-CSF. The median duration was 9 (3-76) weeks. Hospitalization with fever related to neutropenia was significantly less frequent in episodes which received G-CSF (22.2%) than episodes without (66.7%). CONCLUSION: In this study, a significantly lower risk of hospitalization due to fever and neutropenia was associated with administration of G-CSF in patients with absolute neutrophil counts lower than 500 x 10(6)/l.

[Rhodococcus equi in HIV infected patients: 2 new cases]. / Rhodococcus equi en pacientes con infección por el VIH: dos nuevos casos.

We reported two HIV infected patients with bacteremia and pneumonia due to Rhodococcus equi. None of them had suffer any opportunistic infection before this episode. Clinical presentation includes respiratory tract symptoms of subacute onset and fever. The X-ray examination in both cases revealed pneumonia and lung abscess in upper lobes as well as lung infiltrates in other lobes. The microorganism was isolated in lung fine needle aspiration, bronchoalveolar lavage and blood cultures in both cases. One patient died and the other was under antibiotic treatment 5 months after discharge. The therapeutic options in this infection must include the use of at least two different antibiotics to which the microorganism is sensitive, and for a prolonged period of time. Surgical treatment should be considered if the evolution is poor.

Candidal meningitis in HIV-infected patients: treatment with fluconazole.

Although mucocutaneous candidiasis is a common occurrence in HIV-infected patients, candidal meningitis is uncommon. We report 3 cases of candidal meningitis in HIV-positive patients, all intravenous drug abusers, and we discuss the clinical course and outcome, the treatment with fluconazole and possible prophylaxis.

[Respiratory infection caused by Pseudomonas aeruginosa in patients with HIV infection]. / Infección respiratoria por Pseudomonas aeruginosa en pacientes con infección por VIH.

OBJECTIVE: Descriptive study of severe respiratory infections caused by Pseudomonas aeruginosa in patients with HIV infection. METHODS: Review of clinical records of HIV-positive patients admitted in a tertiary hospital from 1-1-1990 to 9-30-1995. The patients included in this study were those with P. aeruginosa recovered from respiratory or blood samples and respiratory symptoms. RESULTS: Forty patients suffered 77 episodes. The incidence in the HIV-positive admitted population during the study period was 2.6% but 3.2% in the last year. Ninety-seven percent of patients met criteria for AIDS. Twenty-eight patients (70%) had other bacterial infections. In 78% of patients no classical predisposing factor was found for this infection. Twenty-seven patients (67.5%) came regularly to the day hospital or had been previously admitted to the hospital (recent hospitalization). Twenty-five episodes (32.5%) were tracheo-bronchitis and 50 pneumonias (65%), of which 14 (28%) were cavitated and 7 (14%) bacteremic. Forty-nine percent of episodes were recurrences. Ten out of 15 tracheo-bronchitis in the first episode recurred; the new episode was more severe in 7 patients. Five patients received secondary prophylaxis after the second episode (4 with tobramycin in aerosol and 1 with colistin in aerosol). Two patients had recurrences after 86 and 62 days (mean: 74; SD: 12). Eight out of the 11 patients who did not receive prophylaxis (73%) had recurrence after a mean of 23 days (SD: 10) (p = 0.002). The mortality rate associated with P. aeruginosa was 22.5%. CONCLUSIONS: The incidence of P. aeruginosa infections in our HIV-positive patients was 2.6% (3.2% in the last year). It is associated with severe immunosuppression and previous bacterial infection. The subacute involvement of the lower respiratory tract is most common. Over 50% of infections tend to recur more severely. The secondary prophylaxis increased the symptom-free period, although the number of patients who received it was small.

[Prospective 3-month study of intravascular catheter complications in HIV-infected patients: relation between phlebitis and infection]. / Estudio prospectivo de 3 meses sobre complicaciones de catéteres intravasculares en pacientes infectados por el HIV: relación entre flebitis e infección.

BACKGROUND: The aim of this study was to evaluate the etiology of phlebitis (chemical or infectious) and the prevalence of infections related to intravascular catheters (IRIC) in patients with HIV infection admitted to a 22-bed Infectious Disease Unit with a high rate of HIV infection. MATERIAL AND METHODS: A 3-month prospective study from November 1, 1994 to January 31, 1995 was carried out following a formula for data collection of all the intravenous catheters used during that time period. Cultures of the catheters withdrawn on Wednesdays and those with signs of phlebitis were performed. RESULTS: One hundred fifty-two intravenous catheters in 71 patients with HIV infection with a mean age of 37 years (range: 21-73) and mean hospital stay of 10.2 days were reported. During the study period 42 phlebitis were produced, of which 37 catheters (7 central and 30 peripheral) were processed. Of the 37 phlebitis processed, 29 (78.9%) were considered to be of physiochemical origin. Of the 21 catheters withdrawn Wednesday, 18 were processed, 8 with phlogotic signs, 2 with IRCI, equivalent to 1.9 IRCI/100 days of catheterization. During the study period no local or severe systemic infections related to the catheter were reported. Staphylococcus epidermidis was the organism involved in all the cases of IRCI. CONCLUSIONS: Despite the high number of immunosuppressed patients in related to HIV infection, a greater incidence of IRCI was not found in these patients. The most frequent cause of phlebitis by catheter was of chemical origin.